Sunday, March 17, 2013

Nanny Knows Best

Warning! Things that are good for you in small amounts may be bad for you in large amounts!

Shocked? No? Well, congratulations, you're one step ahead of the media, which has apparently just discovered the "too much of a good thing" phenomenon. Always reaching for titillating new ways to fill air time in between natural disasters and terrorist attacks, news outlets are focusing on prescription drugs, and opiates in particular, as the latest Terrifying Thing That Might Kill You At Any Moment.

Which is not to say there isn't a problem. Health advocates, such as these officials in Florida, have observed that the number of deaths due to prescription drug overdose far exceeds that of deaths due to illegal drugs such as cocaine and heroin (or, of course, marijuana, which has resulted in exactly zero overdose deaths). In 2009, approximately 38,000 people nationwide died as a result of drug overdoses. If Florida's figures are consistent with national trends, we can assume that about 28,000 of those deaths were due to prescription drugs.

28,000 deaths; 28,000 tragedies. Every year. So yes, there's a problem. But as we search for solutions, let's not overlook another important number: 100,000,000. One hundred million is the number of Americans suffering from chronic pain, for which prescription drugs are the most effective legal path for relief. Put another way: every day, one in three of your fellow citizens goes to work, plays with grandchildren, runs errands—in other words, lives his life—while in pain. For every terrible, wasteful death associated with prescription medications, there are thousands of individuals whose lives would be shattered without them.

Unfortunately, chronic pain is so dog-bites-man. Boring. CNN isn't going to get all hot and bothered about some guy who doesn't lose his home because pain meds enabled him to work—not when they have dead celebrities, real ad-inventory movers like Whitney Houston, Heath Ledger, Brittany Murphy, Anna Nicole Smith, or Michael Jackson.

Now that's a story!

But, hey, don't take the talking heads' word for it. Bring on the journo-docs! Under the hot lights, even generally responsible types, like CNN's Sanjay Gupta, tend to over-focus on the risks at the expense of the context. The point out that, for example, the FDA believes we're in the midst of "an opioid epidemic". But when the context is tens of millions of people suffering chronic pain or other symptoms relieved by prescription drugs, context matters. Because, if you take these arguments to their ad absurdum conclusions, the only "logical" choice is to prohibit or severely restrict access to the meds that provide relief for all those millions of everyday people.

Think nobody is calling for that? Think again. Mayor Michael Bloomberg, fresh off his victory against the corporate titans of Big Cola, is now taking on New York's addiction problem by moving to limit the supply of pain medications in city hospitals. (This effort, and another in Colorado, are focused on emergency room care specifically, which seems prima facie reasonable, until one considers the huge number of patients still receiving their primary care in ERs.)

Of course, once they're on a roll, it's hard to slow the journo-docs and the politinannies down. After all, other drugs can also be dangerous, right? Gotta make sure people can't get their hands on them. Recently, my daughter had a nasty sinus headache. Due to the late hour, I had to drive all over the county to find an open pharmacy that would sell me the decongestant pseudoephedrine (which is also a key ingredient in one recipe for methamphetamine), thanks to regulations that inconvenience patients a lot more than they trouble drug dealers. (Did I mention that there are other recipes for meth that don't require pseudoephedrine at all?)

Eventually, the medical chicken littles inevitably begin to bump into one another. In a recent piece in the Jewish Journal of Los Angeles, columnist Dr. Albert Fuchs wrote of the dangers of the common, effective cough suppressant, Tessalon.

Coughing can be very disruptive to work and to sleep, and patients can be desperate for relief. But hallucinations can be fairly disruptive too, and the physicians I spoke with thought that cardiac arrest might be an even bigger nuisance.

Wow: take a little yellow pill, have a heart attack. Scary stuff. Except that none of the sources he cites actually warn of any such risk in adult patients taking the appropriate dosage. Dr. Fuchs goes on to quote one such source (out of context) suggesting that codeine might be preferable to Tessalon (again, the original context is children, whereas Dr. Fuchs is specifically referring to adults).

Hey—wait a minute. I thought the problem was opiates. Codeine is an opiate, right? You bet it is. You see, once you take away one type of medication because it's dangerous, you have to offer another to treat the symptoms for which the original drug was prescribed. And then... uh oh! That one's dangerous too; maybe the old drug was better. Apparently, in pharmacology, as in life, the grass is always greener on the other side of the regulatory fence.

The vast majority of addicts did not get that way following their doctor's advice or carefully reading labels. Unlike those with chronic pain, or persistent cough, those addicts are suffering (at least to some extent) as a result of their own choices. Prescribing meds, taking them, or giving them to your children are fraught activities deserving of respect. Extra caution should always be exercised when giving drugs to children, and both children and adults should always be concerned about proper dosage and interactions.

But the solution isn't to limit access to drugs that are effective and safe when used properly. Instead, let us demand that pharmaceutical firms label appropriately, and doctors counsel wisely, avoiding hyperbole and fads, so that we may permit adults the dignity of making informed choices about their own care.

To be fair, some of the other methods of methamphetamine synthesis involve anhydrous ammonia which is very, very, very unpleasant.

That said, I'm surprised you didn't touch on this point: if addicts are going to be addicted to drugs, is it even our position to impose regulation to stop that in the first place? A person has the right to his own body to the extent he's not using it to harm others.

The problem is that addicts, depending on the substance they are using, may hurt others just by getting behind the wheel of a car while on drugs. Even riding a bicycle into traffic while high can cause much death and destruction that was unintended by the addict whom no one saw the need to help (or stop). The addicts rights are trumped by the right to life and liberty of those who may be hurt as a result of the addicts actions. No one lives in a bubble. (Well, except for that kid in the movie who actually did live in a bubble. :)

That's why driving while intoxicated isn't legal. What's had _substantially_ more effect than the regulation of opiates on prevalence of DUI's has been education, which reduced the number of drunk driving accidents per mile driven by a factor of three. And unlike regulating prescription drugs, educating people doesn't involve limiting the liberties of others.